Heather Thiesset

Liver transplantation in septuagenarians receiving model for end-stage liver disease exception points for hepatocellular carcinoma: the national experience.

Current liver allocation policy in the United States grants liver transplant candidates with stage T2 hepatocellular carcinoma (HCC) a priority Model for End‐Stage Liver Disease (MELD) score of 22, regardless of age. Because advanced age may portend an increase in all‐cause mortality after transplantation for any diagnosis, the aim of this study was to examine overall posttransplant survival in elderly patients with HCC versus younger cohorts. Based on Organ Procurement and Transplantation Network data, Kaplan‐Meier 5‐year survival rates were compared. Recipients undergoing primary liver transplantation were stratified into cohorts based on age (<70 or ≥70 years) and the receipt of MELD exception points for HCC. Log‐rank and Wilcoxon tests were used for statistical comparisons. In 2009, 143 transplants were performed for patients who were 70 years old or older. Forty‐two percent of these patients received a MELD exception for HCC. Regardless of the diagnosis, the overall survival rate was significantly attenuated for the septuagenarians versus the younger cohort. After 5 years of follow‐up, this disparity exceeded 10% to 15% depending on the populations being compared. The 1‐, 2‐, 3‐, 4‐, and 5‐year actuarial survival rates were 88.4%, 83.2%, 79.6%, 76.1%, and 72.7%, respectively, for the patients who were younger than 70 years and 81.1%, 73.8%, 67.1%, 61.9%, and 55.2%, respectively, for the patients who were 70 years old or older. Five‐year survival was negatively affected for patients with HCC who were younger than 70 years; this disparity was not observed for patients with HCC who were 70 years old or older. In conclusion, although patients who are 70 years old or older compose a small fraction of transplant recipients in the United States, patients in this group undergoing transplantation for HCC form an even smaller subset. Overall, transplantation in this age group yields outcomes inferior to those for younger cohorts. However, unlike patients who are less than 70 years old and receive MELD exception points, overall liver transplant survival is not affected by HCC at an advanced age. Liver Transpl 18:423–433, 2012.

Plasmapheresis and Intravenous Immune Globulin Improve Neurologic Outcome of Central Pontine Myelinolysis Occurring Post Orthotopic Liver Transplant

OBJECTIVE To report 2 cases of central pontine myelinolysis (CPM) post liver transplantation in which treatment with plasmapheresis and intravenous immune globulin improved expected neurologic outcome. CASE SUMMARY Two patients who underwent orthotopic liver transplant developed CPM early in their postoperative course. Magnetic resonance imaging of the brain demonstrated severe demyelination of either the pons or the midbrain, respectively. Both patients developed significant neurologic abnormalities, including acute mental status changes, severe muscle weakness, spasticity, and/or prolonged paralysis. Pretransplant laboratory results indicated serum sodium levels fluctuating between 115 mEq/L and 152 mEq/L. Both patients received 6 days of plasmapheresis (PP) followed by 5 consecutive days of intravenous immune globulin (IVIG). Significant neurologic improvement was experienced at 2 and 4 weeks, respectively, after therapy was initiated. Complete resolution of neurologic symptoms was evident at 1 year follow-up. DISCUSSION Currently, specific guidelines or recommendations for the treatment of CPM are practically nonexistent. CPM remains a neurologic complication that is difficult to treat and may result in permanent significant neurologic sequelae. The etiology and pathogenesis of this disease are unclear, although aggressive osmolar correction, particularly in the setting of hyponatremia, is the main risk factor. While patients may eventually show some improvement with supportive care, progress is often protracted, and complete resolution of symptoms is exceedingly rare. The severity of the midbrain lesions juxtaposed against the rapidity of symptom resolution in these 2 patients alludes to a potential therapeutic benefit after initiation of therapy with PP and IVIG. CONCLUSIONS These cases suggest that prompt recognition of CPM and initiation of PP and IVIG may help modulate its progress and improve long-term neurologic outcome.

Minimally invasive aortic valve replacement with orthotopic liver transplantation: report of a case

Cardiac surgery and liver transplantation (LT) are rarely performed at the same time, because of the potential risks of coupling two such complex surgical procedures [1–3]. This combined surgery is typically reserved for patients with structural heart disease, including multivessel obstructive coronary artery disease and severe valvular disease with heart failure and end-stage liver disease, in whom the untreated organ may decompensate if only one organ is addressed [4]. Combined aortic valve replacement (AVR) and LT is the rarest of such combined surgery, with only ten cases published previously. We present the first reported case of combined minimally invasive AVR and LT and review the literature on similar combined surgery.

Perceived Benefits of a Transplant Surgery Experience to General Surgery Residency Training

OBJECTIVES The benefit of a solid-organ transplant experience during general surgical training has been questioned recently. In 2008, in response to an American Board of Surgery (ABS) directive, a survey was conducted by the Association of Program Directors in Surgery (APDS) in coordination with the American Society of Transplant Surgeons (ASTS) to determine the perceived value of a transplant surgery rotation to program directors and residents. With the aim of providing additional insight, we conducted a separate study, independent of the ABS and ASTS, to ascertain resident perceptions regarding the specific skill sets that they acquire during their transplant surgery rotations and their applicability to other surgical subspecialties. METHODS A preliminary, 51-item, web-based questionnaire was completed by 69.6% of residents in nationally accredited general surgery programs who accessed the survey. The results were examined using appropriate statistical methods to determine associations between answers. RESULTS Although only 16.6% of participants responded that they were considering a career in transplantation, 63.4% answered that the skill sets acquired during this rotation would assist them in their surgical careers regardless of their chosen specialty. Most (65.5%) respondents answered that the techniques learned were directly applicable to other specialties, such as vascular, urologic, trauma, and hepatobiliary surgery. Free response questions indicated that the most common criticisms of this rotation were the limited amount of operative participation, lack of teaching by attendings, and lifestyle limitations. CONCLUSIONS The results of this study indicate that surgery residents are conflicted regarding their transplant surgery experience but regard it as a beneficial addition to their training. Most respondents indicated also that these skills were transferable directly to other surgical specialties.

Using the modern Silverhawk™ atherectomy catheter to characterize biliary structures that appear malignant: review of initial experience

BACKGROUND Diagnosis of a biliary stricture often hinges on cytological interpretation. In the absence of accompanying stroma, these results can often be equivocal. In theory, advanced shave biopsy techniques would allow for the preservation of tissue architecture and a more accurate definition of biliary pathology. OBJECTIVES We sought to determine the initial diagnostic utility of the modern Silverhawk™ atherectomy (SA) catheter in the evaluation of biliary strictures that appear to be malignant. METHODS A total of 141 patients with biliary pathology were identified during a retrospective review of medical records for the years 2006-2011. The SA catheter was employed 12 times in seven patients for whom a tissue diagnosis was otherwise lacking. RESULTS Neoplasia was definitively excluded in seven specimens from four patients. These four individuals were followed for 1-5 years to exclude the development of cholangiocarcinoma (CC). Samples were positive for CC in three patients, one of whom became eligible for neoadjuvant therapy and orthotopic liver transplantation. CONCLUSIONS The SA catheter appears to be a useful adjunct in diagnosing patients with biliary pathology. The existence of this technique, predicated on tissue architecture, may impact therapy, allow more timely diagnosis, and exclude cases of equivocal cytology. Although the initial results of SA use are promising, more experience is required to effectively determine its clinical accuracy.

Revisiting the Issue of VTE in the Setting of Chronic Liver Disease: An Examination of National Surgical Quality Improvement Program Data

examined the rate of VTE in patients with chronic liver disease (CLD), as stratifi ed by international normalized ratio (INR) levels. Specifi cally, the authors retrospectively examined the rate of inpatient VTE occurring over a 7-year period. Of 190 patients with CLD, the authors noted a VTE incidence of 6.3%, with no signifi cant differences in the incidence of VTE between INR quartiles. The majority of patients with documented VTE were classifi ed as Child-Pugh stage C. From this, the authors concluded that an elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. As the cause of VTE is often multifactorial and early initiating factors are still not fully understood, 2 we agree that an elevated INR, in and of itself, is not protective against VTE in the population of patients with CLD. Like the authors, we were also curious regarding the rate of VTE in patients with CLD, particularly after major hepatic resection. After obtaining the appropriate approval from the University of Utah institutional review board (IRB_00030671), we queried the National Surgical Quality Improvement Program (NSQUIP) database to collect data on the number and type of liver resections performed nationally during the years 2004 to 2009 ( Current Procedural Terminology codes 47120, 47122, 47125, and 47130). The incidence of inpatient DVT ( International Classifi cation of Diseases, Ninth Revision , codes 453.4 and 453.8) and PE ( International Classifi cation of Diseases, Ninth Revision, codes 415.9 and 415.11) were examined retrospectively. During the 5-year study period, 6,084 liver resections were performed among 268 NSQUIP institutions nationwide. During this time, the annualized incidence rate remained relatively constant, with DVT and PE occurring at a rate of 1.97% and 1.36%, respectively ( Tables 1 , 2 ). This is not only considerably lower than that experienced by the authors, but also below the estimates typically cited for patients with known malignancies. 2

Mucocele mimicking a gallbladder in a transplanted liver: A case report and review of the literature

Biliary mucoceles after deceased donor liver transplantation are a rarity, and mucoceles mimicking a gallbladder from the recipient remnant cystic duct have not been described until this case. We describe a 48-year-old male who presented with right upper quadrant pain and was found to have a recipient cystic duct mucocele 3 mo after receiving a deceased donor liver transplant. We describe the clinical presentation, laboratory and imaging findings (including the appearance of a gallbladder), multidisciplinary approach and surgical resolution of this mucocele originating from the recipient cystic duct, and a review of the literature.

Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation

Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation To limit recurrence and intra-operative tumor dissemination at the time of transplant, there is increasing evidence that neoadjuvant chemoradiation and brachytherapy boost helps facilitate successful liver transplantation in patients with earlystage unresectable hilar cholangiocarcinoma. In published reports, a complete response to neoadjuvant therapy frequently limits the ability to detect residual disease in the hepatectomy specimen, thereby inviting criticism over whether published results are due to the neoadjuvant protocol per se, or selection of patients with earlystage or pre-malignant disease. In this report, a 41 year old male with a malignant biliary stricture received 45 Gy external beam radiation in conjunction with 5-fluoruracil as a prelude to transplant. This was followed by a transluminal boost of radiation (2000 cGy) using an Iridium-192 brachytherapy wire inserted through percutaneously-placed biliary catheters. Using this approach, we document the complete resolution of the patient’s malignant stricture, thereby objectively quantifying tumor response prior to orthotopic liver transplantation.